Thursday, April 28, 2011

Should the government be able to dictate to a doctor what he or she is allowed to discuss with a patient? Yes, says the National Rifle Association (NRA), which is pushing state legislation to prohibit physicians from asking patients about firearms in their homes.

An NRA-supported bill in Florida originally would have made it a criminal offense—punishable by fines and/or jail—if physicians asked a patient about firearms. The Florida Medical Association (FMA) fiercely opposed the bill as an intrusion on the physician-patient relationship. Now, a compromise has been reached between the NRA and the FMA that “allow doctors to ask questions about gun ownership, as long as the physician doesn’t ‘harass’ the patient, and doesn’t enter the information into the patient’s record without a good reason.” Violations would be policed by the state licensing board instead of being subject to criminal prosecution.

A long-standing ACP policy encourages physicians “to inform patients about the dangers of keeping firearms, particularly handguns, in the home and to advise them on ways to reduce the risk of injury.” But this issue is much bigger than guns, it is about whether the government should be allowed to tell physicians what they can and can’t say to patients.

Bob Centor of DB’s Medical Rants calls the NRA bill an “outrageous” attack on the doctor-patient relationship. He links to a must-read blog from a gun owing ER physician from Texas who explains why no physician should support the NRA bill—including the compromise.

I am not going to second-guess the difficult decisions made by the Florida Medical Association. But I agree with Dr. Centor that it is “outrageous” that the government would even consider dictating to a doctor what he or she can say to a patient. If this isn’t big government at its worst, tell me what is?

If the government can ban physicians from asking patients about firearms, what’s next? Will legislators sympathetic to the cattle industry try to prohibit physicians from asking patients about their consumption of steaks? Will advocates for legalized marijuana try to prohibit physicians from asking patients about their use of drugs? Where does it stop?

And where are all of the “constitutional conservatives” who carry copies of the U.S. constitution in their pockets? Are they raising their voices against the NRA and its state legislature sycophants over this egregious attack on the first amendment right to free speech? If the NRA succeeds in Florida and other states in getting physicians thrown in jail if they violate a government-dictated speech, then how can I as a patient trust anything that my doctor tells me in the examination room?

Today’s question: What do you think about the NRA’s effort to pass laws to dictate to doctors what they can and can’t say to their patients?

Friday, April 22, 2011

And my internist is not a “provider” of health care services. He is my doctor, and I am his patient. Yet politicians, economists, and policy wonks want to turn the intimate doctor-patient relationship into a simple economic transaction between a buyer (consumer) and seller (provider) of services.

Paul Krugman, himself a Nobel Prize winning columnist, writes about this in yesterday’s New York Times:

“How did it become normal” he asks, “or for that matter even acceptable, to refer to medical patients as ‘consumers’? The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car — and their only complaint is that it isn’t commercial enough. What has gone wrong with us?”

Taking off on his theme, Krugman criticizes plans by House Republicans to “replace Medicare with vouchers” by arguing that “‘consumer-based’ medicine has been a bust everywhere it has been tried.” But not only does he think vouchers won’t work, he thinks, “there’s something terribly wrong with the whole notion of patients as ‘consumers’ and health care as simply a financial transaction.”

Now, let’s for a moment put aside Krugman’s political views and his specific criticism of the voucher proposal. (It isn’t just conservatives who refer to physicians as “providers” and patients as “consumers”—I did a search of how many times the words “providers” and “consumers” show up the Affordable Care Act, and found that “provider(s)” is used 620 times and consumer(s) 190 times, although the law also refers to patient(s) 603 times, and physicians 563 times.)

Doesn’t Krugman’s point resonate with you, regardless of your politics? Isn’t there something terribly wrong with medicine being taken over by the bean-counters and budget analysts who look at health care only as a transfer of economic goods from one person to another?

If a physician is just a provider, why should he or she be entitled to any greater respect or standing than a car salesman? If physicians are just a providers, who can blame physicians when they act like car salesmen, trying to maximize personal gain by selling more services to me, the consumer? If doctors are just “providers” aren’t we inviting the culture that Atul Gawande says he found in McAllen, Texas, “a medical community [that] came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.” If physicians are just providers, what’s wrong with them providing more and earning a good living while doing it? And aren’t professionalism and ethics obsolete if medical care is nothing more than an economic transaction between the provider and the consumer?

We complain about doctors that are being squeezed to see more and more patients per hour—but if they are just providers, what is wrong with paying them based on how much care they provide each hour (otherwise known as productivity)?

If I am just a consumer, isn’t it my fault if something doesn’t quite go right with my health and I end up “consuming” more from the system than is my fair share? If I am a just a consumer, I am supposed to be able to shop around for a doctor, right? Just like I did for that new flat screen TV? But that’s not easily done when it’s a sick elderly parent who is admitted for emergency surgery, is it? Or you yourself are facing a frightening illness? Or if I don’t know who is a good doctor or a not-so-good one? And if I am just a consumer, isn’t it all my fault if I didn’t put aside thousands of dollars each year in case my mother might someday end up in a nursing home?

If we look at medical care simply as an economic transaction between “providers” and “consumers” then we shouldn’t be surprised if people act based principally on economic self-interest—the consumer getting as much as he can for as little cost as possible, and the provider earning as much as she can at the highest cost possible. Conservatives might try to alter the economic incentives by making the consumer accept more financial responsibility and letting insurance companies control the supply of services, and liberals might try to do it by having the government control the supply of services through price controls and limits on capacity. But either way, they are missing the point, which is that health care costs are ultimately the very personal and personalized decisions made by physicians and their patients in the examination room or bedside. We need to respect and support that relationship and help doctors and patients make good decisions together, rather than turning them into the equivalent of a used car salesman selling a lemon to a hapless consumer.

Today’s question: Do you agree that “there’s something terribly wrong with the whole notion of patients as ‘consumers’ and health care as simply a financial transaction?”

Wednesday, April 20, 2011

Last week, the House GOP passed a budget framework, authored by budget committee chairman Paul Ryan, which would make fundamental structural changes in Medicare and Medicaid. Democrats already are running ads against potentially vulnerable Republicans saying that they “voted to end Medicare.”

This is a case where the Democrats are trying to do to Republicans what Republicans did to Democrats before the mid-term election — scare seniors. The House GOP’s pre-election Pledge to America stated that the Affordable Care Act’s “massive Medicare cuts will fall squarely on the backs of seniors, millions of whom will be forced off their current Medicare coverage;” this accusation was a staple of Republican ads against vulnerable Democrats.

But guess what? The Ryan budget would repeal just about everything in the Affordable Care Act except the law’s Medicare reductions. ABC news reports that “in a postelection reversal, House Republicans are supporting nearly $450 billion in Medicare cuts that they criticized vigorously last fall after Democrats and President Barack Obama passed them as part of their controversial health care law.” Included in the Ryan budget are the cuts in payments for Medicare Advantage plans that they had charged would cause “millions” to lose their current Medicare coverage. The GOP explains the turn-around on the grounds that the Democrats took money from seniors to expand entitlements for someone else, whereas they will use the savings to “strengthen Medicare” and lower the deficit. I am not sure that seniors will buy the distinction.

But what about the Democrats’ scare tactic that the Ryan plan will “end Medicare?” Well, I guess it depends on how old you are and the meaning of the word “end.”

I am 55 years old, my wife is 53. Under the Ryan plan, I would be able to enroll in the traditional Medicare program when I turn 65, and presumably, could stay in it for the rest of my life. My wife, though, wouldn’t have that option. Instead, she—and everyone else who is now younger than age 55 – would get a set amount of money from the federal government to go out and buy a “standard” package of benefits from a private insurance company. This would effectively “end” the government’s open-ended legal guarantee that Medicare will pay for all covered services, no matter what they cost.

Which is exactly the point of the Ryan plan: he wants to cap the government’s cost exposure as part of a long-term plan to reduce federal spending.

But it would fall to my wife, and others who fall on the wrong side of the age cut-off for traditional Medicare, to pay the difference between the government’s contribution and the actual cost of benefits. And the gap is big and would increase over time, according to the Congressional Budget Office. CBO estimates that in 2022, a typical 65-year-old would pay 61 percent of the cost—premiums and out of pocket costs—of the standard insurance package under the Ryan proposal, while the same 65-year-old would pay 27 percent under CBO’s baseline projections for traditional Medicare. In 2030, the beneficiary’s share would be 68 percent under the Ryan proposal, compared to 25 percent under traditional Medicare. The bottom-line, according to CBO, is that “a typical beneficiary would spend more for health care under the [Ryan] proposal than under CBO’s long-term scenarios for several reasons. First, private plans would cost more than traditional Medicare because of the net effect of differences in payment rates for providers, administrative costs, and utilization of health care services, as described above. Second, the government’s contribution would grow more slowly than health care costs, leaving more for beneficiaries to pay.”

I haven’t yet broken the news to my wife that I could get a better benefit than she.

So does the House-approved budget (Ryan plan) end Medicare, as the Democrats charge? Not for current seniors, not for me, not for anyone age 55 or older. Their effort to scare current seniors into thinking that they will lose their Medicare benefits is not supported by the facts, just as the GOP’s efforts to scare seniors before the mid-term elections was similarly misleading.

But when my (slightly younger than me) wife turns Medicare age, under the GOP plan, she would get a voucher that would require that she pay more at the outset, and progressively more over time. Republicans will argue that this cost-shift is necessary to prevent a fiscal train wreck and to “strengthen Medicare” so that it doesn’t go broke. Perhaps, but there is no question in my mind that for my wife, it would end Medicare’s open-ended guarantee that the government will pay for seniors’ covered benefits, and she’d pay more as a result.

Thursday, April 14, 2011

Many years ago, a professor in one of my political science classes told us to “look beyond the numbers” when trying to make sense of the federal budget. His point was that budget-making is really about making hard policy choices. The dollar numbers reflect the policy choices made by Congress and the President, he said, so if you want to know what their priorities are, follow the money and see which programs get more or less. This may sound self-explanatory—duh!—but I bring it up now because until yesterday, the budget debate often seemed to be more about the dollars than the policy choices involved. That is, the numbers (achieving a pre-determined level of spending cuts) has been driving the policy, rather than policy (deciding what we want, on a program-by-program basis, and then deciding how much of we can actually afford) driving the numbers. Recall that Republicans promised in their pre-election “Pledge to America” to reduce non-defense discretionary spending by $100 billion out of the current fiscal year budget. How they came up with $100 billion—why not $150 billion, or $80 billion?—no one knows. My guess is that it sounded like a nice and high enough number that they could take to voters concerned about federal spending. After winning control of the House of Representatives, Republicans have worked diligently to find a way to get to $100 billion. (And whether you agree with their proposed cuts or not, they deserve credit for trying to deliver on their promises.) On a purely party-line vote with no Democratic support, the House passed a bill in February to cut spending by over $60 billion (GOP leaders explained that because the federal government already was well into its fiscal year, the $60 billion for the remainder of the year was equivalent to $100 billion spread over an entire year). This budget would have rolled back most “discretionary” spending to 2008 levels while sparing national defense. To get to the number, the GOP proposed deep cuts or elimination of many federal programs. The House’s budget—called a continuing resolution, because it provided continued funding for the rest of the government’s current fiscal year, which ends on September 30—was never taken up by the Democratically-controlled Senate, so it went nowhere. (Keep in mind that the reason why the new Congress has had to rely on continuing resolutions to keep the government open is because the 111th Congress, controlled by Democrats, didn’t even bother to pass a budget for this fiscal year.) Later, the GOP-controlled House and the Democratic-controlled Senate negotiated a short-term continuing resolution with about $10 billion in cuts that ran out on April 8, which the GOP House leadership indicated was another step toward getting to the equivalent of $100 billion in cuts. And last week, they reached an agreement on a budget through the end of the fiscal year that would cut another $39 billion, including cuts in funding for some health programs, narrowly averting a partial federal government shut-down. The fight over the current fiscal year budget, though, is small potatoes compared to the battle over future budgets. Last week, the GOP upped the ante by putting forth a budget proposal, authored by budget committee chair Rep. Paul Ryan (R-WI), to cut projected federal spending by $6 trillion, starting with the 2012 federal budget year, which begins on October 1. Unlike the current budget agreement that mostly affects only this year’s discretionary spending—about 12.3% of the budget—the Ryan budget tackles entitlement spending by fundamentally restructuring Medicare and Medicaid. The federal government would give the states the responsibility to run (what used to be) Medicaid as they see fit—states, not the federal government, would decide who to cover and what benefits would be offered. But states would get almost $1 trillion less from the federal government to help pay for health care for the poor. Medicare would be converted from an open-ended entitlement to a defined contribution model: the government would chip in a set amount for seniors to buy coverage from private insurers, and they would be responsible for any medical costs above that amount. (People who today are age 55 and over would still have the option of traditional Medicare when they turn 65.) The federal contribution would be indexed to overall inflation, not to health care cost increases that consistently have out-paced inflation, so the value of the federal contribution would erode over time, putting more of the responsibility on the enrollee to make up the difference. The Ryan budget would also repeal the Affordable Care Act, and with it, the federal government’s promise to ensure that nearly everyone has guaranteed access to coverage. Finally, the Ryan plan puts all of the deficit reduction on the spending side by cutting taxes by over $4.2 trillion and ruling out any future tax increases. Yesterday, President Obama countered by offering a plan to reduce the deficit by $4 trillion over the next decade. He said he would get to this amount by cutting both defense and domestic discretionary spending; increasing revenue through elimination of tax “expenditures” and itemized deductions for high-earners and allowing many of the Bush tax cuts expire; and achieving savings in Medicare and Medicaid. But unlike the Ryan plan, the President unabashedly pledged to preserve Medicare and Medicaid much as they are today, but with more cost savings by controlling health care spending. Among other savings, he proposed to give Medicare the authority to negotiate drug prices and to give an Independent Payment Advisory Board, created by the Affordable Care Act, more authority to impose cost controls if necessary. I expect that much of the coverage following Obama’s speech will again be about the numbers—how much would his plan cut spending and lower the debt compared to the Ryan budget? But the more important thing is that the Ryan budget and the Obama speech begin to frame the policy choices involved, especially when it comes to health care. As Robert Pear wrote in yesterday’s New York Times, lawmakers “face several fundamental questions: Will the federal government retain its dominant role in prescribing benefits and other details of the program, like how much doctors and hospitals are paid and which new treatments are covered? Will beneficiaries still have legally enforceable rights to all those services? Will Medicare spending still increase automatically with health costs, the number of beneficiaries and the amount of care they receive? Or will the government try to limit the costs to taxpayers by paying a fixed amount each year to private health plans to subsidize coverage for older Americans and those who are disabled?” This is a debate worth having, because it gets at the difficult policy questions and the very different policy priorities of each party, rather than looking at the budget simply as a fight over numbers. Today’s questions: What do you think Representative Ryan’s and President Obama’s budget proposals say about the choices that must be made? How would you answer Robert Pear’s “fundamental question” of whether “Medicare spending still increase automatically with health costs, the number of beneficiaries and the amount of care they receive?” or should “the government try to limit the costs to taxpayers by paying a fixed amount each year to private health plans?”

Friday, April 8, 2011

According to some state legislators, the answer is yes. Lawmakers in South Carolina are pushing legislation that would “make it illegal to transport immigrants anywhere, including a hospital” reports the New York Times. Fox News Phoenix reports that in Arizona, a bill has been introduced to “require hospitals, when admitting nonemergency cases, to confirm that a person seeking care is a U.S. citizen or in the country legally. In emergency cases where the patient isn't here legally, the hospital would be required to call immigration authorities after the treatment is done. Hospitals in non-emergency situations would also be required to contact federal immigration authorities, but they would have more apparent discretion about whether to treat illegal immigrants.”

Such ill-advised efforts by states to criminalize health care for undocumented persons has led the American College of Physicians, the nation’s second largest physician organization, to speak out against “Any law that might require physicians to share confidential information, such as citizenship status to the authorities, that was gained through the patient–physician relationship conflicts with the ethical and professional duties of physicians.” ACP made this statement in a new position paper on immigrants’ access to health care released yesterday at its annual scientific meeting in San Diego, California.

Moreover, ACP argues that, “Access to health care for immigrants is a national issue and needs to be addressed with a national policy. Individual state laws will not be adequate to address this national problem and will result in a patchwork solution.” A national policy on immigrants’ access to health care should include the following elements, says ACP:

- Taxpayers should not be required to subsidize health insurance coverage for persons who are not legal residents of the United States and people should not be prevented from paying out-of-pocket for health insurance based on immigration status.

- The same access to health coverage and government-subsidized health care for U.S.-born children of parents who lack legal residency should be the same as any other U.S. citizen.

- Acknowledgement of the public health risks associated with undocumented persons not receiving medical care because of concerns about criminal or civil prosecution or deportation.

- Immigration policy should include increased access to comprehensive primary and preventive care, and vaccinations and screening for prevalent infectious diseases. This will make better use of public health dollars by improving the health status of this population and alleviating the need for costly emergency care.

- Federal government support for safety-net health care facilities and offsets for costs of uncompensated care provided by these facilities.

- Acknowledgment that physicians and other health care professionals have an ethical and professional obligation to care for the sick. Immigration policy should not interfere with the ethical obligation to provide care for all.

- Policies that do not foster discrimination against a class or category of patients in the provision of health care.

ACP concluded with a “call to action” for a national policy that recognizes the need for the country to control whom it admits within its borders and to differentiate its treatment of those who comply with the law in establishing legal residency from those who do not, while recognizing that hospitals and physicians have an ethical obligation to provide care for residents lacking legal documentation.

Some readers of this blog might question why ACP is wading into the complex, controversial, and polarizing debate over immigrants’ access to health care. (ACP’s paper addresses only questions relating to immigrants’ access to health care, not broader immigration policy.) But in my opinion, ACP should be praised for confronting an issue that affects health care for tens of millions of persons in the United States, documented and undocumented alike. As ACP President Fred Ralston, MD, MACP remarked at yesterday’s press event, “Access to health care for immigrants is crucial to the overall population of the U.S. We all have a vested interest in ensuring that all residents have access to necessary care.”

If physicians don’t speak up for their patients, even those who lack legal residency, who will? Not federal and state politicians, that’s for sure.

Today’s question: What is your reaction to ACP’s call for a national policy on access to care for immigrants that is in accord with physicians’ ethical obligation to care for the sick?

Tuesday, April 5, 2011

When I talk to internal medicine audiences around the country about the latest health policy flavor of the day - accountable care organizations (ACOs) - a typical reaction is skepticism trending toward cynicism. Many don’t quite get what ACOs are all about and certainly don’t want to be lectured about how they need to re-invent their practices. And they don’t buy the idea that ACOs will somehow save internal medicine primary care. The same can be said, perhaps to a lesser extent, about their reactions to PCMHs (Patient-Centered Medical Homes), P4P ( pay-for-performance), HIT (health information technology), MU (meaningful use), and the whole alphabet soup of other reforms being proposed to reform health care delivery and payment systems.

And who can blame them? Older internists have seen this all before, and the word has gone out from them to medical students and younger doctors not to trust policy prescriptions that promise to save primary care.

In the 1970s, doctors were told that HMOs would allow primary care internists to focus on wellness and prevention (that is why they were called “health maintenance organizations,” after all) and they would be paid appropriately for keeping their patients well. HMOs, of course, became managed care, which for most primary care doctors meant even more paperwork for even less money.

In the 1980s, they were told if they became gatekeepers, they would be back in charge of the system and be paid appropriately for it. A 2004 retrospective New York Timesop-ed by Lisa Sanders, MD, titled “The Death of Primary Care” recounts the promise and perils of gatekeeping. She noted that in 1985, [the late] John Eisenberg, an internist and ACP fellow, wrote in the Annals of Internal Medicine that the gatekeeper concept ''sanctifies the internist's role as primary care physician and captain of the patient's ship.'' Maybe the idea could have worked if insurance companies didn’t turn it into a paper chase for authorization forms, but instead, as Dr. Sanders observed, “the gatekeeper kept people away from otherwise available specialists. It was a job despised by doctors and loathed by patients.”

In the early 1990s, the RBRVS was going to improve reimbursement for the “cognitive services” provided primary care physicians. It did some good for at least awhile, but the RBRVS begat the RUC, budget-neutrality conversion factor adjustments, behavioral offset assumptions, resource-based practice expenses, and its evil twin sister, the SGR – and a whole lot of other processes and policies. Now, some twenty years after the RBRVS first went into effect, payments to primary care doctors in the trenches have fallen even further behind other specialists. In the mid-1990s, it was capitation that was going to make things better, but capitation ended up being a transfer of insurance risk onto the back of the beleaguered primary care doctor, with the perverse effect that internists who took care of the most complex patients were paid the least!

Now it is P4P, PCMHs, HIT, MU, and ACOs that are supposed to save primary care, right? Given the history of other failed policy interventions, skepticism trending toward cynicism is a perfectly justifiable reaction from primary care internists.

The problem with cynicism, though, is that it can be an excuse from holding on to a status quo that itself is not sustainable. If every new idea is rejected because other ones didn’t work as expected, then primary care will remain stuck where it is right now—over-worked and under-valued.

The challenge, then, for those of us who believe that change is necessary and even inevitable, is to show that the PCMHs, ACOs, and other ideas for reforming payment and delivery systems can really work for the doctors in the trenches. Articles in prestigious journals, white papers from policy conferences, and well-meaning policy papers from organizations like ACP won’t hack it. We will instead need to demonstrate that the new models really, really, really can result in better payment, more time with patients, and fewer hassles for real doctors in real practices. We will have to fight to make sure that what seems like good ideas aren’t hijacked by insurance companies and other special interests into something entirely else, like we saw with gatekeepers and the resource-based relative value scale.

Like the legendary refrain from the legendary rock band, The Who, primary care doctors are screaming that they won’t be fooled again, and policy advocates would have to be deaf, dumb and blind not to hear them.

Today’s questions: What do you think the history of other failed policies tell us about the latest ideas for saving primary care?

P.S. I will be blogging from ACP’s annual scientific meeting in San Diego all week, and will be moderating several educational sessions on health care reform on Friday, April 8. Check the scientific program guide under the “Ethics and Health Policy” track for more details. Hope to see you there!